John William THORPE · Prevention of Future Deaths report

On 8th April 2014 I commenced an investigation into the death of John William THORPE, age 78. The investigation concluded at the end of the inquest on 19th June 2014. The conclusion of the inquest was SUICIDE.

In February 2014 the deceased consulted ████████ Foundation Year 2 trainee doctor at Swineshead Medical Group Practice, for non-specific symptoms including low mood. A variety of investigations were initiated, with no significant pathology being elucidated.

He again consulted ████████ on 12th March 2014 complaining of feeling more tired and with low mood. Feelings of hopelessness and self-harm were elucidated. A PHQ-9 screening test was administered with a score of 16/27 being obtained, indicative of moderately severe depression. Mr Thorpe was given a prescription for 20 milligrams of the anti-depressant fluoxetine daily and asked to self-refer himself to "IAPT" (Improving Access to Psychological Therapies). He was given no firm appointment to be seen again at the practice, but the plan noted in the clinical records was to see him again in 1 months time.

On 24th March 2014, Mr Thorpe left his home, taking his dogs for a walk. His dogs were found tethered to a railing adjacent to the Forty Foot Drain, a large drainage dyke, at Swineshead Bridge. Footprints, matching his boots were found tracking down into the dyke and he was found floating in the middle of the dyke.
The post mortem indicated that the cause of death was drowning and that he had been taking fluoxetine regularly in the days before his death as well as diphenhydramine.

1. That the deceased was asked to "self-refer" himself to IAPT rather than a direct referral being made on his behalf to an appropriate mental health resource. His widow was particularly critical of this at the Inquest, commenting she attempted to fill the form in for him but it wasn't completed and she believed her husband would have responded if a direct referral had been made. I appreciate this may be 'standard practice' but the point is surely not in every case and Doctors should be encouraged to use their discretion more

2 That no intention to follow him up, with a definite appointment being given or by telephone contact, is recorded in the clinical records.

3 That ████████ knowledge, elicited at the inquest, that "sometimes when anti-depressant is started it can give you more energy" and that Mr Thorpe had a history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants, viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk, where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed".